Humana: Lucentis Payer Policy (Beta Access)

TABLE OF CONTENTS

• Humana: Lucentis Payer Policy (Testing)
  • Line of Business
  • Precertification/Prior Authorization
  • Step Therapy
  • Diagnoses and Criteria
    • Neovascular (Wet) Age-Related Exudative Macular Degeneration (AMD)
    • Diabetic Macular Edema (DME)
    • Diabetic Retinopathy (DR)
    • Macular Edema Following Retinal Vein Occlusion (RVO)
    • Myopic Choroidal Neovascularization (mCNV)
  • Exclusions
  • Dosage and Administration
  • Additional Notes
  • Sources

This policy outlines the coverage criteria for Lucentis®, a recombinant monoclonal antibody and vascular endothelial growth factor (VEGF) inhibitor administered via intravitreal injection. It is indicated for multiple ophthalmological conditions and requires prior authorization for approval.

Line of Business

This policy applies to the following lines of business:

• Medicare
• Commercial
• Medicaid – Florida
  • Step therapy requirements do not apply.
• Medicaid – Kentucky
• Medicaid – South Carolina
• Medicaid – Ohio
  • Prior authorization applies.

The effective date is January 1, 2025, with a revision date of January 1, 2025, and a review date of May 15, 2024.-(Medicare, Medicaid: Florida, Kentucky, South Carolina, and Ohio) 

Precertification/Prior Authorization

• Required: Yes, prior authorization is required for all covered indications.

Step Therapy

• The member must have a contraindication, intolerance, or inadequate response to bevacizumab.
• State-Specific and Line-of-Business Details:
  • For Medicare Part B requests, step therapy does not apply if the request is a continuation of prior therapy within the past 365 days.
  • For Florida Medicaid, step therapy requirements are not applicable.

Diagnoses and Criteria

Neovascular (Wet) Age-Related Exudative Macular Degeneration (AMD)

• Diagnosis of neovascular (wet) age-related macular degeneration.
• Step therapy requirements apply unless exempt under Medicare Part B or Florida Medicaid.
• Approval Duration: Approval is for the plan year duration or as determined through clinical review.

Diabetic Macular Edema (DME)

• Diagnosis of diabetic macular edema.
• Step therapy requirements apply unless exempt under Medicare Part B or Florida Medicaid.
• Approval Duration: Approval is for the plan year duration or as determined through clinical review.

Diabetic Retinopathy (DR)

• Diagnosis of diabetic retinopathy.
• Step therapy requirements apply unless exempt under Medicare Part B or Florida Medicaid.
• Approval Duration: Approval is for the plan year duration or as determined through clinical review.

Macular Edema Following Retinal Vein Occlusion (RVO)

• Diagnosis of macular edema following retinal vein occlusion.
• Step therapy requirements apply unless exempt under Medicare Part B or Florida Medicaid.
• Approval Duration: Approval is for the plan year duration or as determined through clinical review.

Myopic Choroidal Neovascularization (mCNV)

• Diagnosis of myopic choroidal neovascularization.
• Step therapy requirements apply unless exempt under Medicare Part B or Florida Medicaid.
• Approval Duration: Approval is for the plan year duration or as determined through clinical review.

Exclusions

• Lucentis is contraindicated in:
  • Patients with ocular or periocular infections.
  • Patients with active intraocular inflammation.
• Concurrent use of Lucentis with other VEGF inhibitors is not recommended unless documentation specifies that the products are being used in different eyes.

Dosage and Administration

• Lucentis is available as:
  • 0.5 mg (10 mg/mL) solution for intravitreal injection.
  • 0.3 mg (6 mg/mL) solution for intravitreal injection.

Additional Notes

• Lucentis binds to and inhibits VEGF-A, reducing abnormal blood vessel growth and leakage in the retina.
• Dosage limits beyond those specified for FDA-approved indications are not detailed in this policy.

Sources: https://mcp.humana.com/tad/tad_new/home.aspx?type=provider